Patients' experience of rehabilitation after stroke

Stroke Survivor's Satisfaction and Experience with Rehabilitation Services: A Qualitative Systematic Review

Research in healthcare is increasingly focused on quality assurance and continuous quality improvement aiming to promote service quality. Satisfaction is a key endpoint in outcomes research and service benchmarking, along with "traditional" clinical outcomes. What controls stroke survivors' satisfaction differs among qualitative studies' conclusions, but there is general consensus on the importance of communication, improvement in activity, and engagement in goal setting. This review aims to collect and synthesise studies of the satisfaction of stroke survivors with rehabilitation services. A systematic search was conducted in seven electronic databases, including CINAHL, OVID, Pedro, Scopus Midline, Web of Science, and PubMed. The database search yielded 1339 studies, while one additional work was identified through hand searching. After removing duplicates, 74 studies were read in full, and after resultant exclusions, 12 qualitative studies were systematically reviewed, extracted, and appraised by two reviewers independently (HAS and RT) and the third reviewer (CS) was available for any disagreement. Five analytical themes were identified: Healthcare Professional-Patient Relationship (HCP), Delivery Service, Perceived Patient Autonomy (PPA), Expectations Shape Satisfaction, and Culture Influences Satisfaction. The studies of survivors' satisfaction, experiences, and their rehabilitative needs with the services they receive have provided different factors that influence their satisfaction during rehabilitation in different countries worldwide. However, the context in which the studies were conducted is quite limited, and more detailed studies are required for many underexplored contexts.

Have We Forgotten Our Patient? An Exploration of Patient Experiences After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Limited information is available on the experiences of patients during rehabilitation after anterior cruciate ligament reconstruction (ACLR).

AIM

The current study aimed to identify factors that differentiated positive and negative patient experiences during rehabilitation after ACLR.

METHOD AND DESIGN

A survey-based study with an online platform was used to identify factors that differentiated positive and negative patient experiences during rehabilitation after ACLR. Seventy-two patients (age 27.8 [8.8] y) after ACLR participated. Data were analyzed and themes were identified by comparing categories and subcategories on similarity.

MAIN FINDINGS

Positive patient experiences were room for own input, supervision, attention, knowledge, honesty, and professionalism of the physiotherapist. Additionally, a varied and structured rehabilitation program, adequate facilities, and contact with other patients were identified as positive patient experiences. Negative experiences were a lack of attention, lack of professionalism of the physiotherapists, a lack of sport-specific field training, a lack of goal setting, a lack of adequate facilities, and health insurance costs.

CONCLUSIONS

The current study identified factors that differentiated positive and negative patient experiences during rehabilitation after ACLR. These findings can help physiotherapists in understanding the patient experiences during rehabilitation after ACLR.

The Role of Social Interactions in Motor Performance: Feasibility Study Toward Enhanced Motivation in Telerehabilitation

BACKGROUND

Robot-mediated telerehabilitation has the potential to provide patient-tailored cost-effective rehabilitation. However, compliance with therapy can be a problem that undermines the prospective advantages of telerehabilitation technologies. Lack of motivation has been identified as a major factor that hampers compliance. Exploring various motivational interventions, the integration of citizen science activities in robotics-based rehabilitation has been shown to increase patients' motivation to engage in otherwise tedious exercises by tapping into a vast array of intrinsic motivational drivers. Patient engagement can be further enhanced by the incorporation of social interactions.

OBJECTIVE

Herein, we explored the possibility of bolstering engagement in physical therapy by leveraging cooperation among users in an environmental citizen science project. Specifically, we studied how the integration of cooperation into citizen science influences user engagement, enjoyment, and motor performance. Furthermore, we investigated how the degree of interdependence among users, such that is imposed through independent or joint termination (JT), affects participation in citizen science-based telerehabilitation.

METHODS

We developed a Web-based citizen science platform in which users work in pairs to classify images collected by an aquatic robot in a polluted water canal. The classification was carried out by labeling objects that appear in the images and trashing irrelevant labels. The system was interfaced by a haptic device for fine motor rehabilitation. We recruited 120 healthy volunteers to operate the platform. Of these volunteers, 98 were cooperating in pairs, with 1 user tagging images and the other trashing labels. The other 22 volunteers performed both tasks alone. To vary the degree of interdependence within cooperation, we implemented independent and JTs.

RESULTS

We found that users' engagement and motor performance are modulated by their assigned task and the degree of interdependence. Motor performance increased when users were subjected to independent termination (P=.02), yet enjoyment decreased when users were subjected to JT (P=.005). A significant interaction between the type of termination and the task was found to influence productivity (P<.001) as well as mean speed, peak speed, and path length of the controller (P=.01, P=.006, and P<.001, respectively).

CONCLUSIONS

Depending on the type of termination, cooperation was not always positively associated with engagement, enjoyment, and motor performance. Therefore, enhancing user engagement, satisfaction, and motor performance through cooperative citizen science tasks relies on both the degree of interdependence among users and the perceived nature of the task. Cooperative citizen science may enhance motivation in robotics-based telerehabilitation, if designed attentively.

Adapted dance used in subacute rehabilitation post-stroke: impacts perceived by patients, relatives and rehabilitation therapists

Purpose: To examine the perceived impacts of an adapted-dance group intervention when added to intensive functional rehabilitation post-stroke.Method: In this exploratory qualitative case study, semi-structured interviews were analyzed using a deliberative inductive logic and referring to the International Classification of Functioning, Disability and Health. Participants were patients in rehabilitation post-stroke (≤25 days) (n = 6), relatives (n = 4) and rehabilitation therapists (n = 12). Selection was on a voluntary basis. The intervention added to the patients' rehabilitation program consisted of 55-minute bi-weekly sessions for 10 weeks.Results: Three categories of perceived positive impacts emerged from the data: (1) mobility, (2) mental functions and personal factors (emotional functions, motivation and self-efficacy) and (3) interpersonal interactions and social life. A fourth category of perceived impacts involving exercise tolerance was both positive, in terms of general physical endurance, and negative, in terms of a feeling of increased fatigue.Conclusion: Such an adapted-dance intervention holds promise in subacute rehabilitation post-stroke. Its main strength lies in its perceived positive impact on mental functions, personal factors, and interpersonal and social interactions.Implications for rehabilitationAn adapted-dance group intervention could offer an innovative means of contributing to intensive functional rehabilitation post-stroke by potentially generating positive perceived impacts on emotional functions, motivation and self-efficacy, as well as on interpersonal and social interactions.Adapted dance could be added to inpatients' rehabilitation with only minor impacts on fatigue.

A Framework for Designing Inpatient Stroke Rehabilitation Facilities: A New Approach Using Interdisciplinary Value-Focused Thinking

Aim:

To use Value-Focused Thinking to investigate what is important in the design of inpatient stroke rehabilitation facility buildings.

Background:

Many stroke patients require inpatient rehabilitation in a dedicated facility. Rehabilitation facilities are healthcare spaces, but they are also learning spaces where patients practice targeted tasks to acquire new skills and to reacquire skills and abilities that were compromised as a result of their stroke. There is currently no consensus regarding how the design of inpatient rehabilitation facilities could be optimized for patients’ learning.

Method:

We used Value-Focused Thinking to develop a framework of what interdisciplinary experts consider important for inpatient stroke rehabilitation facility design. Two workshops were conducted. The following experts were invited to participate: past patients with experience of stroke rehabilitation; stroke rehabilitation clinicians; stroke rehabilitation academics; healthcare environments academics; learning environments academics; architects, designers, and wayfinders with experience designing healthcare or learning environments; and healthcare design policy makers.

Results:

Thirty experts participated. The experts’ final framework included 16 criteria that were considered fundamentally important for inpatient stroke rehabilitation facility design, and 14 criteria that were considered instrumentally important. Inpatient stroke rehabilitation facility design should maximize efficiency, maximize effectiveness (i.e., patients’ clinical and functional outcomes), foster emotional well-being, and maximize safety. Opportunities to practice physical, cognitive, and social activity were considered important for patients’ outcomes.

Conclusions:

Value-Focused Thinking was an effective and equitable means of engaging experts from multiple disciplines. Designers, planners, and developers of inpatient stroke rehabilitation facilities should consider the rehabilitation-specific framework developed in this study alongside evidence from other healthcare settings.

Rehabilitation environments: Service users' perspective

Background

Design of rehabilitation environments is usually “expert” driven with little consideration given to the perceptions of service users, especially patients and informal carers. There is a need to engage with consumers of services to gain their insights into what design aspects are required to facilitate optimum physical activity, social interaction and psychological responses when they are attempting to overcome their limitations and regain function.

Research design

Qualitative exploratory study.

Method

Interviews were conducted with patients (n = 54) and informal carers (n = 23), and focus groups with rehabilitation staff (n = 90), from the three metropolitan South Australia rehabilitation health services, comprising different building and environmental configurations. Thematic analysis was assisted by the use of NVivo 11 qualitative software, with pooled data from all interviews and focus groups undergoing open, axial and finally selective coding.

Results

Four major themes were identified as follows: (a) choice can be an Illusion in a rehabilitation ward; (b) access to outside areas is a priority and affects well‐being; (c) socialization can be facilitated by the environment; and (d) ward configuration should align with the model of care.

Discussion and Conclusion

Participants who encountered the most restrictive environments accepted their situation until probed to consider alternatives; those who enjoyed the most choice and access to facilities showed the greatest enthusiasm for these affordances. Future architectural designers should therefore consider the perceptions of a wide range of consumers with varying experiences to ensure they understand the complex requirements of patients and that the ward design facilitates the optimum rehabilitation model of care.

Perspective of patients and caregivers about stroke rehabilitation: the Quebec experience

BACKGROUND

The unique perspectives of patients and caregivers on their experiences as users of rehabilitation services help identify areas for improvement for the continuum from acute care to community integration.

OBJECTIVE

This study reports perceptions of persons with stroke and their caregivers in an existing continuum of stroke care, social services, and rehabilitation in the Province of Quebec.

METHODS

A total of 10 focus groups were held, 5 with persons with stroke (n = 37, mean age 59.6 years (SD = 11.6); 21 men) and 5 others with caregivers (n = 31; mean age 58.8 years (SD = 15.1); 8 men). Discussions were transcribed and were the object of thematic content analysis using Nvivo.

RESULTS

Participants expressed their general satisfaction toward the care received in inpatient, hospital, and rehabilitation settings. The information received about acute care, however, was deemed insufficient and fragmented, and access of rehabilitation services was often perceived to be difficult. In the community integration phase of the continuum, most participants stated that they had experienced poor accessibility to services of any kind.

CONCLUSIONS

Persons with stroke and their relatives' perspectives about the services that they obtained throughout the rehabilitation continuum vary importantly according to the services examined. Adopting a continuum perspective is helpful to target priorities for improvement.

Factors Influencing the Overall Satisfaction in Patients With Severe Brain Injury With Physiotherapy Services During Inpatient Rehabilitation

OBJECTIVE

To determine what influences the satisfaction of rehabilitation inpatients and their relatives with physiotherapy after severe traumatic brain injury.

DESIGN

A prospective purpose-designed survey of consecutive eligible patients discharged from a metropolitan brain injury unit.

PARTICIPANTS

A total of 65 patients with severe traumatic brain injury and 32 relatives.

RESULTS

The vast majority of patients (99%) and relatives (97%) reported being "satisfied" or "highly satisfied" with the service. Patients' overall satisfaction was influenced by the extent of actual and perceived improvement, satisfaction with certain aspects of service delivery, and quality of interaction with physiotherapy staff. Satisfaction with the amount of therapy was the key determinant for patients' overall satisfaction, whereas relatives' overall satisfaction was influenced primarily by how well they felt they were listened to by physiotherapy staff.

CONCLUSION

The high satisfaction of the patients and relatives suggests that our brain injury unit provides physiotherapy that meets their expectations. Promoting recovery, providing high-quality care, and ensuring good interaction are ways to maintain high satisfaction of patients and relatives with the service. In addition, staff may have to pay particular attention to patients' satisfaction with the amount of therapy and ensure that relatives' needs are listened to.

‘If only I manage to get home I'll get better’-Interviews with stroke patients after emergency stay in hospital on their experiences and needs

Objective: To find out about the experiences of stroke patients concerning their falling ill, their stay in hospital, discharge and homecoming.

Design: Qualitative methods using in-depth interviews.

Subjects and setting: Nine strategically chosen patients and in five cases near family members were interviewed in their homes four months post stroke and following care at the Stroke Centre, University Hospital of Northern Sweden, Umea°.

Results: Three main categories with subcategories were brought to the fore from the interviews: ‘Responsible and implicated’, ’Depersonalized object for caring measures’ and ‘The striving for repersonalization and autonomy’. The patients got the most important insights and understanding about their state and the consequences when they came home.

Conclusion: The three main categories that were found mirror the crisis which becoming ill entails and the process gone through when the individual takes control again of his or her life. The patients saw coming home as an important factor for their recovery and rehabilitation. The health care system needs to develop strategies to make use of the power of this attitude with the patients and to use the patients' own milieu in rehabilitation after stroke.

Stroke survivors' perspectives on two novel models of inpatient rehabilitation: seven-day a week individual therapy or five-day a week circuit class therapy

PURPOSE

To explore stroke survivors' perspectives of two novel models of inpatient physiotherapy, which provide an increased amount of therapy: five days a week circuit class therapy and seven days a week individual therapy.

METHOD

This is a qualitative descriptive study using semi-structured interviews and thematic analysis. The participants were 10 purposively sampled stroke survivors in the post-acute phase of recovery, who had experienced seven days a week individual therapy or five days a week circuit group therapy during inpatient rehabilitation.

RESULTS

Three main themes emerged from the data: Too much, too little or just right; My experience - alone and together; and Meeting my needs. Findings revealed considerable variety in participants' beliefs, priorities and preferences regarding how intensely they could work; their experience of success and challenge individually and collectively; and their need to have their own unique individual needs met. Lack of choice seemed to be a linking concept between the themes.

CONCLUSION

In order to provide patient-centred services, novel methods of increased therapy must take into consideration the individual needs and preferences of the people accessing them. One model may not meet all these needs, hence a "menu" of options for therapy sessions (different timing, frequency, duration, content, rest and supervision) may be required to accommodate the diversity of patient needs, preferences and capacities. Implications for Rehabilitation People with stroke have diverse needs and preferences regarding the modes of delivering more therapy during rehabilitation. These diverse needs may not be met by one rigid service model. Therapists and service providers could engage their clients in a dialogue about the need for more therapy and how it can be delivered. This dialogue could include options of the various ways to increase their therapy. Therapists need to provide clear reasons and education around therapy components, including rest time and practice schedules.

Patients' expectations of coming home with Very Early Supported Discharge and home rehabilitation after stroke - an interview study

BACKGROUND

An Early Supported Discharge (ESD) and rehabilitation from a coordinated team in the home environment is recommended in several high-income countries for patients with mild to moderate symptoms after stroke. Returning home from the hospital takes place very early in Sweden today (12 days post stroke), thus the term Very Early Supported Discharge (VESD) is used in the current study. The aim of this study was to describe patients' expectations of coming home very early after stroke with support and rehabilitations at home.

METHOD

This is an interview study nested within a randomized controlled trial; Gothenburg Very Early Supported Discharge (GOTVED), comparing VESD containing a home rehabilitation intervention from a coordinated team to conventional care after stroke. Ten participants (median age 69) with mild to moderate stroke symptoms (NHISS 0 to 8 points) were recruited from the intervention group in GOTVED. Interviews were conducted 0-5 days before discharge and the material was analyzed with qualitative content analysis.

RESULTS

Four main categories containing 11 subcategories were found. The VESD team was expected to provide "Support towards independency", by helping the participants to manage and feel safe at home as well as to regain earlier abilities. The very early discharge gave rise to expectations of coming home to "A new and unknown situation", causing worries not to manage at home and to leave the safe environment at the ward. A fear to suffer a recurrent stroke when being out of reach of immediate professional help was also pronounced. In contrast to these feelings of insecurity and fear, "Returning to one's own setting" described the participants longing home, where they would become autonomous and capable people again. They expected this to facilitate recovery and rehabilitation. "A new everyday life" waited for the participants at home and this was expected to be challenging. Different strategies to deal with these challenges were described.

CONCLUSIONS

The participants described mixed expectations such as insecurity and fear, and on the other hand, longing to come home. Moreover, they had a high degree of confidence in the expected support of the VESD team. The health professionals at the hospital may build on this trust to reduce the patients' insecurity for coming home. In addition, it may be beneficial to explore the patients' expectations thoroughly in front of discharge, as certain feelings and thoughts could complicate or support the home coming process. Thus, a greater attention on such expectations may facilitate the patient's transition from hospital to home after stroke.

Exploring Client-Centered Care Experiences in In-Patient Rehabilitation Settings

Patient or client-centered care has been widely accepted as an essential component of health care delivery in many countries. Few studies explore actual implementation of client-centered principles and clients’ and health care providers’ (HCPs) experiences with these approaches. Our objective was to explore current models of delivery of rehabilitation services from the perspectives of patients, families, and HCPs. We conducted semistructured interviews with patients, families, and HCPs of one of four rehabilitation facilities in South-Central Ontario, Canada. Being on common grounds/Working toward client set goals was the main category identified by both clients and HCPs. Although successful partnerships were created, the majority of clients assumed a passive position. Clients needed more information about the rehabilitation progression and alternative treatment options. The results of the study suggest that we need to encourage and educate clients to become motivated, well-informed, proactive participants in their care.

Stroke Survivors' Experiences of Physical Rehabilitation: A Systematic Review of Qualitative Studies

OBJECTIVE

To report and synthesize the perspectives, experiences, and preferences of stroke survivors undertaking inpatient physical rehabilitation through a systematic review of qualitative studies.

DATA SOURCES

MEDLINE, CINAHL, Embase, and PsycINFO were searched from database inception to February 2014. Reference lists of relevant publications were searched. All languages were included.

STUDY SELECTION

Qualitative studies reporting stroke survivors' experiences of inpatient stroke rehabilitation were selected independently by 2 reviewers. The search yielded 3039 records; 95 full-text publications were assessed for eligibility, and 32 documents (31 studies) were finally included. Comprehensiveness and explicit reporting were assessed independently by 2 reviewers using the consolidated criteria for reporting qualitative research framework. Discrepancies were resolved by consensus.

DATA EXTRACTION

Data regarding characteristics of the included studies were extracted by 1 reviewer, tabled, and checked for accuracy by another reviewer. All text reported in studies' results sections were entered into qualitative data management software for analysis.

DATA SYNTHESIS

Extracted texts were inductively coded and analyzed in 3 phases using thematic synthesis. Nine interrelated analytical themes, with descriptive subthemes, were identified that related to issues of importance to stroke survivors: (1) physical activity is valued; (2) bored and alone; (3) patient-centered therapy; (4) recreation is also rehabilitation; (5) dependency and lack of control; (6) fostering autonomy; (7) power of communication and information; (8) motivation needs nurturing; and (9) fatigue can overwhelm.

CONCLUSIONS

The thematic synthesis provides new insights into stroke survivors' experiences of inpatient rehabilitation. Negative experiences were reported in all studies and include disempowerment, boredom, and frustration. Rehabilitation could be improved by increasing activity within formal therapy and in free time, fostering patients' autonomy through genuinely patient-centered care, and more effective communication and information. Future stroke rehabilitation research should take into account the experiences and preferences of stroke survivors.

Stroke in young women: An interpretative phenomenological analysis

Stroke among adults of working age is increasing. We aimed to explore the experience of stroke among young women in Ireland. In total, 12 women (aged between 18 and 50 years) participated in semi-structured interviews. Data were analysed using interpretative phenomenological analysis. Four super-ordinate themes were identified: stroke as an illness of later life ('obviously it's for older people'), post-stroke selves, a desire for peer support and the impact of stroke on relationships. Findings indicate the importance of addressing the specific needs of younger stroke patients from admission to recovery through provision of inclusive all-age acute stroke services with tailored rehabilitation.

Patients value patient-therapist interactions more than the amount or content of therapy during inpatient rehabilitation: a qualitative study

QUESTION

How do patients receiving inpatient rehabilitation experience physiotherapy and does their experience differ if they receive extra Saturday physiotherapy?

DESIGN

Qualitative study using in-depth interviews and thematic analysis. Interviews were audio-taped, transcribed, member checked and coded independently by two researchers. Data were triangulated using published quantitative data.

PARTICIPANTS

Nineteen adults undergoing inpatient rehabilitation for neurological and musculoskeletal impairments who received either usual care (Monday to Friday therapy) or additional Saturday therapy.

RESULTS

One main theme (personal interactions), and five sub-themes (empathetic and caring physiotherapists, socialisation with other patients, alleviated boredom, changed perceptions of the weekend, and contentment with amount of therapy) emerged from the data. Patients valued interacting with physiotherapists and other patients. Patients were content with the amount of physiotherapy whether or not they had additional Saturday physiotherapy. However, having additional Saturday physiotherapy changed the patients' perceptions of Saturdays; patients who received Saturday physiotherapy viewed Saturday as a day where they would be working towards improving their function, while patients who did not receive Saturday physiotherapy expected to rest on the weekend.

CONCLUSION

The patient-therapist interaction was more important to the patient than the amount or content of their physiotherapy, but Saturday therapy changed patients' perceptions of weekends in rehabilitation.

Physiotherapy practice in stroke rehabilitation: a cross-sectional survey of physiotherapists in the state of Kerala, India

BACKGROUND

Physiotherapy, a major component of rehabilitation for stroke patients, has been shown to have a positive effect on outcome. However, there is debate over efficacy of different interventions related to stroke rehabilitation.

PURPOSE

The purpose of this study was to compare knowledge and attitudes of physiotherapists working with stroke patients in Kerala, India, with emphasis on demographics, approach to treatment, and beliefs about stroke rehabilitation.

METHODS

Two hundred one physiotherapists in Kerala were surveyed using questionnaires, which were sent by post. Questionnaires consisted of items related to stroke rehabilitation such as approaches to physiotherapy, use of walking aids, and discharge issues. Data analysis was done using percentage-wise comparisons.

RESULTS

Examination of results showed variation in the beliefs held by physiotherapists about treatment of stroke patients. Of the 201 respondents, 153 (76.1%) used a conventional treatment approach. There was a strong disparity among physiotherapists regarding use of walking aids by stroke patients: 119 (59.2%) agreed that tripods or quadripods should be given to patients, but 55 (27.4%) disagreed and 27 (13.4%) were unsure. In response to questions about discharge issues, 30 (14.9%) of the 118 respondents agreed that they were actively involved in discharge planning for stroke patients, and 158 (78.6%) agreed that skill of the physiotherapist influences outcomes.

CONCLUSION

A great deal of variation among physiotherapists in treatment approaches and beliefs was revealed in this study, which indicates the need for development and implementation of a standardized protocol for stroke rehabilitation in Kerala.

A Mixed Methods Study of the Experience of Transition to the Community of Working-Aged People with Non-Traumatic Brain Injury

Background and aims: The ‘transition’ phase from hospital to home following brain injury is well established as a critical period of adjustment for individuals and their families. There is, however, a lack of knowledge about the experience of transition following nontraumatic brain injury (e.g., stroke, aneurysm) for individuals of working age. The purpose of this study was to explore the transition experiences of individuals with nontraumatic brain injury using mixed methods approach.

Methods: Six individuals with nontraumatic brain injury were recruited from a larger study using maximum variation sampling criteria. Individuals participated in semistructured interviews at 6-months postdischarge and completed quantitative measures of psychosocial outcomes predischarge and at 6-months postdischarge. Results: Qualitative content analysis of interviews identified three themes: (1) changes in role performance, (2) support and services and (3) coping with life after brain injury. The transition experience was characterised by loss of valued roles including driving and work, identified as major barriers to regaining independence postdischarge. Informal support provided by family and friends were relied on, while formal supports were accessed infrequently. Life post-injury presented a number of challenges including adjusting to changes in physical and cognitive abilities and a fear of reinjury. Qualitative data were supported by an overall trend of improved functioning on the quantitative measures over the 6 months.

Conclusions: Key life circumstances of working age adults with nontraumatic brain injury influence the transition experience. Clinically, the findings support the need for individualised, structured transition services pre- and postdischarge for this group.

Patients' experiences with self-referral to in-patient rehabilitation: A qualitative interview study

PURPOSE

To describe objectives, experiences and satisfaction among subjects referring themselves to in-patient rehabilitation.

METHOD

Persons suffering from stroke or multiple sclerosis were invited to refer themselves to a specialised rehabilitation department. Ten patients referred themselves within the study period, of whom two were excluded. The remaining eight underwent qualitative semi-structured in-depth interviews, focusing on the decision of self-referral, the personal goals for the rehabilitation, and the satisfaction with the stay. The interviews were tape-recorded and subjected to content analysis. As an underlying theoretical framework, we applied Antonovsky's Sense of Coherence model.

RESULTS

Half of the patients had not written the application themselves and did not know which grounds had been put forward in the application. Nevertheless, all the patients were able to formulate their personal goals for the rehabilitation stay. These were distributed in three main categories: those who recently had got a progressive disability wanted education and improved knowledge on their disease; those who had had an acute, traumatic change of health status wanted training in order to improve muscular strength or everyday skills; and those who had been disabled for several years wanted inspiration for further life.

CONCLUSIONS

Patients may put forward other reasons to apply for rehabilitation than health personnel. Does the Sense of Coherence Model seems applicable to describe these reasons.

A systematic review and synthesis of the quantitative and qualitative evidence behind patient-centred goal setting in stroke rehabilitation

Objective: To map out from the literature the nature, extent and effects of application of patient-centred goal setting in stroke rehabilitation practice.

Design: Systematic review.

Data sources: A search was conducted in the Cochrane (Wiley), AMED, Medline (EBSCO), Embase, Sports discuss, Medline (Ovid) and CINAHL databases. Secondary search based on references from the preliminary search was undertaken.

Review methods: Quantitative and qualitative studies that included aspects of patient-centredness and goal setting in stroke patients from 1980 to June 2010 were collected. Studies were scrutinized for relevance and quality based on published methodology. The findings were synthesized by aggregating the themes from the qualitative studies and relating them to relevant findings from the quantitative studies.

Results: Eighteen qualitative and eight quantitative and one mixed method study conducted in stroke rehabilitation services ranging from acute to community rehabilitation were included. Themes that emerged were related to perceptions of patients and professionals regarding patient-centredness, nominal adoption of this concept, consequences of discrepancies in the perceptions and practice, related ethical conflicts, challenges to application and strategies to improve its application. The effects of following patient-centred goal-setting practice have been studied mostly with weak methodologies and studies show some benefit with psychological outcomes.

Conclusion: Patient-centred goal setting is minimally adopted in goal-setting practice due to various barriers. Since the effects of incorporating this concept have not been evaluated rigorously it is suggested that further research is essential to investigate its effect on patient outcomes.

Stroke survivors' experiences of rehabilitation: a systematic review of qualitative studies

INTRODUCTION

The aim was to obtain the best available knowledge on stroke survivors' experiences of rehabilitation. The increase in demands for accountability in health care and acknowledgement of the importance of client participation in health decisions calls for systematic ways of integrating this perspective.

METHODS AND MATERIALS

A systematic review of qualitative studies was performed. A literature search in MEDLINE, CINAHL, PsycINFO, and EMBASE was conducted. Suitability for inclusion was based on selected criteria: published qualitative studies written in English from 1990 to 2008 on stroke survivors' experiences of rehabilitation in a clinical setting. Data analysis entailed extracting, editing, grouping, and abstracting findings.

RESULTS

Twelve studies were included. One theme, "Power and Empowerment" and six subcategories were identified: 1) Coping with a new situation, 2) Informational needs, 3) Physical and non-physical needs, 4) Being personally valued and treated with respect, 5) Collaboration with health care professionals and 6) Assuming responsibility and seizing control.

DISCUSSION

The synthesis showed that stroke survivors' experiences of rehabilitation reflected individual and relational aspects of power and empowerment. The capacity to assume power and empowerment was a dynamic rather than a progressive issue, and enabling empowerment was a matter of weighing contrasting issues against each other, e.g. the right to decide versus the right not to decide.

'We're just sick people, nothing else': ... factors contributing to elderly stroke patients' satisfaction with rehabilitation

Objective: To identify factors contributing to elderly stroke patients' satisfaction with rehabilitation following stroke.

Design: Qualitative study using semi-structured interviews.

Setting: Interviews conducted in two phases, once in a stroke rehabilitation unit and once after hospital discharge.

Subjects: Twelve elderly stroke patients (seven women and five men, aged 60—87 years).

Results: One main category: 'To be treated with respect and dignity' was identified as a core factor contributing to patients' satisfaction with the rehabilitation services. This main factor was divided into five subcategories: (1) Being treated with humanity, (2) Being acknowledged as individuals, (3) Having their autonomy respected, (4) Having confidence and trust in professionals, (5) Dialogue and exchange of information. The statements covered a continuum from satisfaction via indifference to dissatisfaction. Expressions of satisfaction emerged mainly as general statements while expressions of dissatisfaction described situations in greater detail. Satisfaction was merely connected to daily care experiences and fulfilment of basic needs. Trust in providers and being dignified seemed more closely associated with satisfaction than being involved in treatment decisions. The findings demonstrate how the quality of patient—professional interaction influences patients' satisfaction with stroke rehabilitation.

Conclusion: To be treated with respect and dignity seems to be a core element influencing vulnerable elderly stroke patients' satisfaction with rehabilitation. A merely functional definition of the success of rehabilitation should be expanded into an approach encompassing patients' perceptions and personal preferences. The meaning of dignity for elderly stroke patients in the rehabilitation setting should be further clarified and given practical substance.

Rehabilitation needs for older adults with stroke living at home: perceptions of four populations

BACKGROUND

Many people who have suffered a stroke require rehabilitation to help them resume their previous activities and roles in their own environment, but only some of them receive inpatient or even outpatient rehabilitation services. Partial and unmet rehabilitation needs may ultimately lead to a loss of functional autonomy, which increases utilization of health services, number of hospitalizations and early institutionalization, leading to a significant psychological and financial burden on the patients, their families and the health care system. The aim of this study was to explore partially met and unmet rehabilitation needs of older adults who had suffered a stroke and who live in the community. The emphasis was put on needs that act as obstacles to social participation in terms of personal factors, environmental factors and life habits, from the point of view of four target populations.

METHODS

Using the focus group technique, we met four types of experts living in three geographic areas of the province of Québec (Canada): older people with stroke, caregivers, health professionals and health care managers, for a total of 12 groups and 72 participants. The audio recordings of the meetings were transcribed and NVivo software was used to manage the data. The process of reducing, categorizing and analyzing the data was conducted using themes from the Disability Creation Process model.

RESULTS

Rehabilitation needs persist for nine capabilities (e.g. related to behaviour or motor activities), nine factors related to the environment (e.g. type of teaching, adaptation and rehabilitation) and 11 life habits (e.g. nutrition, interpersonal relationships). The caregivers and health professionals identified more unmet needs and insisted on an individualized rehabilitation. Older people with stroke and the health care managers had a more global view of rehabilitation needs and emphasized the availability of resources.

CONCLUSION

Better knowledge of partially met or unmet rehabilitation needs expressed by the different types of people involved should lead to increased attention being paid to education for caregivers, orientation of caregivers towards resources in the community, and follow-up of patients' needs in terms of adjustment and rehabilitation, whether for improving their skills or for carrying out their activities of daily living.

Supporting stroke patients' autonomy during rehabilitation

In a qualitative study, 22 stroke patients undergoing rehabilitation in three nursing homes were interviewed about constraints on and improvements in their autonomy and about approaches of health professionals regarding autonomy. The data were analysed using grounded theory, with a particular focus on the process of regaining autonomy. An approach by the health professionals that was responsive to changes in the patients' autonomy was found to be helpful for restoration of their autonomy. Two patterns in health professionals' approach appeared to be facilitatory: (1) from full support on admission through moderate support and supervision, to reduced supervision at discharge; and (2) from paternalism on admission through partial paternalism (regarding treatment) to shared decision making at discharge. The approach experienced by the patients did not always match their desires regarding their autonomy. Support and supervision were reduced over time, but paternalism was often continued too long. Additionally, the patients experienced a lack of information. Tailoring interventions to patients' progress in autonomy would stimulate their active participation in rehabilitation and in decision making, and would improve patients' preparation for autonomous living after discharge.

Caring and uncaring experiences as narrated by persons with long-term pain after a stroke

The aim of this study was to describe how persons with long-term pain after a stroke experience their care. The study is part of a larger research project concerning a group persons suffering from long-term pain after a stroke. Qualitative interviews were performed with 43 persons suffering from central poststroke pain, nociceptive pain or tension-type headache after their stroke incident. Content congruence emerged among the narratives (n = 43), and therefore the most information-rich ones (n = 23) were selected for deeper investigation by means of qualitative content analysis. The results reveal the patients' need for being respected, understood and supported, also for being given adequate time and information. Accessibility and continuity in the professional contacts and with regard to medical and physical treatment was emphasized. The participants' narratives highlight the importance of the professionals having knowledge of pain and pain management.

Experience of rehabilitation following spinal cord injury: a meta-synthesis of qualitative findings

STUDY DESIGN

Meta-synthesis of qualitative research.

OBJECTIVES

To identify, compare and synthesize published qualitative evidence concerning the experience of rehabilitation following spinal cord injury (SCI).

METHODS

Published articles were identified from the Medline, CINAHL and Sociological abstracts databases, a hand search through selected journals published since 1990, and from reference lists. These were assessed for their relevance to the focus of interest and appraised for rigour. The key themes that emerged from the data were summarized, compared and synthesized.

RESULTS

The search located 64 papers and four books, of which eight papers (describing seven studies) met the review criteria for relevance and rigour. Thematic comparison and synthesis resulted in the identification of seven concepts that encapsulate the important dimensions of rehabilitation from participants' perspectives: (1) the importance of specific staff qualities; (2) the need for a vision of future life possibilities; (3) the importance of peers; (4) the relevance of programme content; (5) the institutional context of rehabilitation; (6) the importance of reconnecting the past to the future; (7) the importance of meeting the needs of the real world.

CONCLUSIONS

If rehabilitation services are to be evidence-based, relevant and effective in meeting the needs of people with SCI they must be informed by the perspectives of people with SCI. The findings of this review suggest that the most important dimension of rehabilitation for people with SCI is the calibre and vision of the rehabilitation staff.

Patient, carer and staff experience of a hospital-based stroke service

OBJECTIVE

Here, the aim is to study the experiences of patients, carers and staff throughout a hospital stroke care pathway.

DESIGN

Focus groups of patients, carers and staff followed a semi-structured format to elucidate experiences. The groups were recorded, transcribed and subjected to thematic analysis. Analyses were verified by researchers and participants.

RESULTS

Patients and carers produced four overlapping themes: 'information', 'staff attitudes', 'availability of care/treatment' and 'considering the whole person in context'. The carers' group produced two additional themes: 'accommodation of patients' individual needs' and 'burden of care'. Their experiences were complex and multi-faceted; positive views of the whole service co-existed with negative views of some aspects. The staff groups produced six themes: 'specialist service', 'split service', 'availability of care', 'consistency of care', 'staff morale' and 'wish for change'. Positive views of the specialist service were tempered by problems with physical and professional separation, staff shortages and 'hierarchical practice' that reduced collective decision-making.

CONCLUSION

Some of the patients' and carers' perspectives have not been previously reported in the stroke literature, including a desire for individualized treatment, the consideration of wider, non-physical needs and the carers' sense of burden. In addition, the study revealed how staff, carers and patients viewed each other and the service and demonstrated the concordance of their perceptions. However, staff showed little insight into the users' need for information and negative experiences of care. In contrast with previous research, lack of emotional care, poor continuity of care and lack of staff knowledge and skills were not identified as problems.

Identification of rehabilitation needs after a stroke: an exploratory study

Background

Services to meet adequate rehabilitation needs of elderly stroke survivors are not always provided. Indeed, since 1995, in the wake of the Quebec shift to ambulatory care, home care services, mainly those related to rehabilitation of the elderly, are either unavailable or incomplete. The aim of this study was to examine the rehabilitation needs of this clientele from their hospitalization to their reintegration into the community.

Methods

The "Handicap Production Process" conceptual approach was chosen to help identify the rehabilitation needs of persons affected by physical or cognitive disabilities due to the interactions between personal and environmental factors, and (activities of daily living, social roles). This qualitative exploratory study was performed in 2003. Data were collected among four groups of experts: patients, caregivers, health care providers and administrators. Data triangulation was used to ensure a rigorous analysis and validity of the results.

Results

Unfulfilled needs could be found in the categories of pertaining to residence, community living, psychological and emotional needs. Indeed, it appears that a psychological follow-up to discuss acceptance and consequences of non-acceptance would facilitate mid-to long-term rehabilitation.

Conclusion

Improving accessibility to healthcare services, respecting priority parking spaces for the disabled as well as promoting public awareness would enable a better social reintegration and recovery of social roles, thus limiting the onset of handicap situations.

The first year of rehabilitation after a stroke - from two perspectives

This phenomenographic study aimed to highlight divergent ways in which a group of people hit by a stroke and their health care professionals understand the implications of having a stroke. Data consisted of interviews with 15 patients (aged less than 65 years) who have had a stroke and transcripts from the health care professionals' recording during the first year of rehabilitation. Three basic conceptions related to the stroke were shared, but the interpretation of these conceptions and the goals of the rehabilitative activities differed. While the patients' experience of the loss of control, fatigue and a fear of a relapse influenced their rehabilitation process, the health care professionals ignored these aspects in their recording. Their focus was more on reduced functions and training. Successful rehabilitation must be based on the conceptions of those who have had a stroke of what it involves. Goals should be explicitly expressed and discussed and be experienced as relevant by the person who has had a stroke as well as by the health care professionals. Measures to assess all the implications of strokes must be developed. The multi-professional perspectives represented amongst the team of health care professionals must be adopted and implemented.

How Stroke Survivors and Primary Support Persons Experience Nurses in Rehabilitation

The role of nursing in rehabilitation has been studied from various perspectives. This study explored experiences with nursing care in rehabilitation from the perspective of stroke survivors and their primary support persons (PSP). The sample consisted of six stroke survivors and seven primary support persons. Through in-depth phenomenological interviews, participants related the experiences with nursing care that stood out for them. The experience was conceptualized as a two-dimensional continuum from helpful to adversarial, with none of the participants articulating a therapeutic presence from nurses. Implications for nursing are explored.

Rehabilitation at home after stroke: a descriptive study of an individualized intervention

OBJECTIVE

To describe the content of a programme involving early hospital discharge and continued rehabilitation at home after stroke.

DESIGN

Quantitative and qualitative descriptive study of an intervention within the context of a randomized controlled trial.

SETTING

Huddinge University Hospital, Stockholm, Sweden.

SUBJECTS

Forty-one patients, moderately impaired after stroke, rehabilitated by a team of six occupational, physical, and speech and language therapists.

RESULTS

The average duration of the programme was 14 weeks, the mean number of home visits 12, and the median total time consumption 23 hours and 20 minutes, of which face-to-face contact with the patient constituted 54%. The rehabilitation process was pursued by the patient and the therapist in partnership. Supported by the team the therapists incorporated a wider domain of activities than usual and left a considerable amount of the training to self-directed activities. The most common foci of the visits were speech and communication, ADL activities and ambulation. When planning the intervention the therapists paid attention to discrepancies between the desires and abilities of the patient on the one hand and environmental demands on the other - discrepancies detected through observation of the patient in the home environment.

CONCLUSIONS

The home environment offers therapists working in a team opportunities to adopt a behaviour that enables patients with moderate neurological impairments after stroke to resume responsibility and influence over their rehabilitation process, resulting in an individualized rehabilitation programme that varies in duration, content and frequency of home visits.

Stroke patients' needs and experiences regarding autonomy at discharge from nursing home

In this qualitative study stroke patients rehabilitating in nursing homes experienced an increase in their autonomy (particularly in self-determination, independence and self-care) in the last weeks before discharge. The change in autonomy was found to be related to regained abilities and self-confidence, and to patients' strategies (e.g. taking initiative, being assertive). The attitude of health professionals and family, and the nursing home could influence patient autonomy. Overprotection, paternalism, care routines and an inconsistent approach constrain autonomy. Conversely, attentiveness, tailored interventions and a respectful dialogue facilitate autonomy, like moderate instrumental and emotional support by the family. Nursing homes can enhance autonomy by minimizing care routines and by providing room for doing activities independently and privately. Attention to patient autonomy may improve patients' active participation in rehabilitation, quality of life, and autonomous living after discharge. Multidisciplinary guidelines based on the results may increase attention to the stroke patients' autonomy and stimulate a team approach.

Rules of relevance after a stroke

In line with the WHO, rehabilitation after a stroke can be viewed as a process of interaction and negotiation between the patient and the health care system about realistic goals and relevant activities. So a relevant question is "Whose understandings and rules of relevance determine the rehabilitation process?" In order to answer the above question the aim of this study was twofold. One aim was to explore how stroke survivors under 65 understand and deal with the activities of the rehabilitation process and how they experience having had a stroke. The second aim was to explore how the same patients and their rehabilitation processes were described in medical records, and ultimately to compare the two results. Ten patients were studied during the first 3 months after their strokes. Data consists of transcripts from interviews with the patients and notes from medical documents. Discourse analysis was used as a methodological approach, and in the analysis the focus was upon the discourse, rather than upon the message itself. The discourse of stroke survivors and health care personnel overlap each other to a great extent. The discourse is a biomedical one and both focus on the physical disabilities of the stroke survivors. The subordinate position of the patients and the authoritative position of the health care providers are also valid for both groups. However, there are also differences. While the stroke survivors portray themselves as individuals having had a position in the society, which they want to recapture, they are portrayed as fragmented male or female bodies of a certain age with certain impairments and dysfunction in the medical records. There is no answer to the question; What is of most importance for the stroke survivors?

Discharge and follow-up for people with stroke: what happens and why

OBJECTIVE

To assess the quality of the process of discharge from hospital and follow-up services for people with stroke.

DESIGN

A criterion-based process audit and basic outcome measures, combined with surveys of patients' satisfaction and staff opinion of the service.

SETTING

All units treating stroke patients in a health care district including an acute and a community NHS trust, and 23 participating GP practices.

SUBJECTS

Process audit: documented notes of 98 stroke patients admitted and discharged over a four-month period. Patient satisfaction survey: 93 surviving stroke patients. Staff opinion survey: general practitioners, hospital doctors, therapists and nurses treating stroke patients throughout the district.

RESULTS

A poor level of service was found. The main shortcomings were poor communication and liaison and a narrow focus of rehabilitation which concentrated on the assessment and provision of basic home care and activities of daily living (ADL) required to obtain discharge. There was a paucity of provision beyond this most basic level and little follow-up after discharge. Pass rates against agreed criteria were: communication between staff and patients/carers 47%, liaison between staff 44%, assessment of home-based needs 48%, assessment of domestic skills 15.5%. Fifty-one per cent of patients were referred for follow-up therapy and of these 72% started follow-up therapy within six weeks of discharge, only 27% had any follow-up assessment of activity levels and well-being. Patients were dissatisfied with the information, support services and therapy they received. The main reasons for the shortcomings were lack of awareness of the services provided, professionals' low expectations of patients' abilities, and limitations of community-based therapy services.

CONCLUSIONS

Evidence from other publications suggests that these results do not indicate a service that is any worse than other districts, rather it represents the poor deal offered to stroke patients. By comprehensively assessing several aspects of the service together this methodology has been able to reveal these inadequacies and the reasons for them.

Investigating recovery from stroke: a qualitative study

A recent randomized controlled trial evaluated the effects of specialist nurses providing information, advice and support to caregivers and patients at home during the first year after a stroke. Reported here are the results of a complementary study which used qualitative methods to examine the experience of patients and caregivers during the year of recovery after a stroke. We used semi-structured interviews with a purposively selected sample of 30 patients and 15 caregivers at the end of a randomized controlled trial (13-16 months post-stroke). Patients and caregivers provided vivid descriptions of the recovery process. Recovery was perceived in terms of the degree of congruence patients identified between their lives before, and after, stroke. Patients therefore had individual and personal yardsticks for measuring their recovery. In conclusion, further research and interventions must consider the diverse, complex, dynamic and highly personal character of stroke recovery. Traditional outcome measures are too simplistic to capture patients' and caregivers' experiences. There do not appear to be single or simple solutions to the problems of facilitating psycho-social adjustment.

The process of stroke rehabilitation: what happens and why

OBJECTIVE

To assess the process of hospital-based stroke rehabilitation.

DESIGN

A criterion-based process audit, combined with surveys of patient and staff opinions and basic outcome measures.

SETTING

All wards and units treating stroke patients in a health care district, including an acute and a community National Health Service (NHS) trust.

SUBJECTS

Process audit: documented notes of 115 stroke patients admitted over a four-month period. Patient satisfaction survey: 93 surviving stroke patients. Staff opinion survey: Hospital doctors, therapists and nurses treating stroke patients throughout the district.

RESULTS

A disappointingly poor level of service. The main shortcomings were poor assessment of impairment (pass rate, 46%), inadequate communication between staff and with patients and carers (pass rate, 43%), and an absence of rehabilitation beyond the basic of activities of daily living and indoor mobility (pass rate for assessment of disability and emotional need, 50%). Thirty-three per cent of patients were dissatisfied with the hospital-based service they received, particularly lack of therapy, information and recovery. The main reasons for these shortcomings were low priority given to stroke patients, lack of time, shortage of staff, and lack of knowledge and awareness of stroke amongst the staff. Rehabilitation units and elderly care tended to perform better than general medical units in areas of assessment of impairment, self-care skills and mobility, and wheelchair provision.

CONCLUSIONS

Evidence from previous publications suggests that this service was no worse than in other districts, but this audit methodology, by comprehensively examining many aspects of a service together, is better able to reveal inadequacies.

Rehabilitation in the home versus the hospital: the importance of context

PURPOSE

Stroke rehabilitation has received increased attention in the past decade. Recent trials with new alternatives such as home-based rehabilitation services are being conducted. The purpose of the study was to explore differences between a therapy session with a stroke patient in two different contexts, i.e. in the patient's home and in the hospital.

METHODS

The research design was a qualitative case study. Three data collection methods were used; participant observations of therapy sessions in two different contexts, semi-structured interviews and documents.

RESULTS

The data were examined and coded for common categories. Analysis of the data looking for similarities and differences in behaviour of two therapists and their patients during therapy sessions in the hospital and in the home was performed. The observations revealed that there was clearly a difference in behaviour; a different role-set used by the two therapists when working in the patient's home versus in the hospital. The major difference in patient behaviour was that the patient, observed in his home, took the initiative and expressed his goals, which was not the case with the patients observed in the hospital. The findings were confirmed in the interviews and the documents.

CONCLUSION

It is suggested that the context is a key component to be considered in the rehabilitation process of stroke patients.

Stroke. 1: A paradigm case in nursing rehabilitation

This is the first of two articles which consider rehabilitation following a stroke. Although stroke is a major cause of morbidity and mortality in the UK there have been relatively few studies describing its long-term effects. Despite relatively good functional recovery, in many cases a number of stroke survivors still experience 'long-term misery'. This article argues for an expanded range of outcomes in stroke rehabilitation and for greater attention to be paid to the psychological needs of stroke survivors and their carers. Areas of deficit in stroke rehabilitation are described, as is the currently poorly developed nursing role.

The role of leisure in stroke rehabilitation

Stroke patients often fail to resume full lives, even if they make a good physical recovery, and social and leisure pursuits show a particular decline. The usual goals of rehabilitation are mobility and independence in self-care, but recovery in a broader sense may be impeded if health professionals concentrate exclusively on these. Leisure has been shown to be closely associated with life satisfaction and would be a worthwhile, and now measurable, goal of rehabilitation. Elderly people show a decline in leisure activity which has been studied extensively and may provide a useful model for the more rapid decline seen in stroke patients. Further research is needed to confirm the finding that specialized occupational therapy can be effective in raising leisure activity, and to show whether this will translate into improved psychological well-being.